SIU Investigator

Job Category:  Claims
Department:  Payment Integrity

Los Angeles, CA, US, 90017

Position Type:  Full Time
Requisition ID:  3861


Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Investigator position is the core of the Special Investigations Unit (SIU).  This position conducts investigations of alleged fraudulent billing and other suspected fraudulent activities related to LA Care, members and providers. The position will work closely with the department heads particularly with the Pharmacy Department on potential fraud and abuse areas.  This position will ensure that they conduct the investigation objectively and are lawfully compliant; and, is thorough in gathering all material facts and present an accurate and objective accounting of the issues.


The SIU Investigator conducts independent investigations resulting from the discovery of suspicious claims or incidents involving L.A. Care, members and service providers that could potentially involve fraud, waste, or abuse. Reviews information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medi-Cal/Medicare policies and initiates appropriate action. Reviews pharmacy reports and utilizes analysis techniques to identify fraud and abuse related to issuance of prescriptions. Completes investigation after referrals to law enforcement (Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS), Department of Justice (DOJ) or local police) and initiate process with L.A. Care’s Recovery Services to recoupment of overpaid monies.
Participates in onsite audits as assigned in conjunction with investigation development. Participates at hearings/appeals and testify as a witness in court.  

Submit referrals of suspected fraud cases within mandated period of time as required by DHCS and CMS. Prepare and submit investigative report documenting all phases of an investigation.  Compiles and maintains various documentation and other reporting requirements. Maintains chain of custody on all documents and follows all confidentiality and security guidelines. Maintains cases referred to law enforcement and responds to requests for information; pursues applicable administrative actions during investigation/case development.

Utilizes data analysis techniques to detect unusual billing claims data, and proactively seeks out and develops leads received from fraud tips and any variety of sources (e.g., fraud alerts, media).

Participate in industry meetings/training and is able to effectively share and gather significant information. Able to liaison with industry peers and where necessary, interface appropriately with law enforcement. Continually enhance investigative skills and understanding or emerging issues and trends impacting the industry. Performs other duties as assigned by Management that contribute to SIU goals and objectives.


High School Diploma/GED

Associate's Degree or Bachelor's Degree


With Bachelor’s Degree:  3-5 years of experience in healthcare fraud investigation/detection with some emphases on pharmacy fraud type cases.

Demonstrated expertise in reviewing, analyzing/developing information, including pharmacy related fraud to include interviewing, report writing and decision making.

Experienced and knowledgeable of schemes related to investigations of pharmacies and members committing fraud and abuse with prescriptions.

With Master’s Degree:  2 years of experience in healthcare fraud investigation/detection with some emphases on pharmacy fraud type cases.

Equivalent Experience:
With High School Degree/GED:  6-8 years of experience in healthcare fraud investigation/detection with some emphases on pharmacy fraud type cases.

With Associate’s Degree: 5 years of experience in healthcare fraud investigation/detection with some emphases on pharmacy fraud type cases.

Professional Certifications

Accredited Health Care Fraud Investigator (AHFI) or
Certified Fraud Examiner (CFE) preferred or willingness to obtain the AHFI certification.


L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)
  • Tuition Reimbursement
  • Retirement Plans
  • Medical, Dental and Vision
  • Wellness Program
  • Volunteer Time Off (VTO)

Nearest Major Market: Los Angeles

Job Segment: Medical, Pharmacy, Claims, Medicare, Medicaid, Healthcare, Insurance